Robotic shoulder repair and reconstruction

ABSTRACT

Methods and surgical system for performing a surgical procedure. The surgical system includes a robotic system with a robotic arm having a surgical instrument attached thereto. A computer system of the robotic system receives at least one image and forms a model of a surgical area. A computer operated tracking system of the robotic system obtains position data related to a patient&#39;s bone from tracking elements. Based on the model of the surgical area and the tracked bone position, the robotic arm then performs the surgical procedure with the surgical instrument, and the robotic system adjusts the procedure as a result of the tracked bone position.

TECHNICAL FIELD

This document pertains generally, but not by way of limitation, tosurgical systems that include robotic systems for the performance ofmedical surgical procedures. More particularly, this disclosure relatesto, but not by way of limitation, automated robotic system assistancefor use in shoulder arthroplasty and related surgical procedures.

BACKGROUND

Surgical procedures are exceptionally delicate and require significantskill by the surgeon performing the surgery. Typically, precision duringsurgery is paramount to ensure the best outcome possible for thepatient. During surgical procedures, such as reaming a bone or placingan implant, precision is necessary for a successful surgery. Reaming toomuch bone, providing too much or too little tension on implants,misplacing implants, and the like can have serious health effects. Theseinclude need for follow up surgeries, loss of a range of motion, orfailed implant equipment.

Surgical procedures related to joints in the body provide their ownunique problems. For example, the shoulder joint is a complex joint withthe scapula, clavicle and the humerus all coming together to enable awide range of movement, at least in a properly functioning joint. In aproperly functioning shoulder joint the head of the humerus fits into ashallow socket in the scapula, typically referred to as the glenoid.Articulation of the shoulder joint involves movement of the humeral headin the glenoid, with the structure of the mating surfaces andsurrounding tissues providing a wide range of motion.

When the shoulder joint is damaged for any reason, including rheumatoidarthritis, osteoarthritis, rotator cuff arthroplasty, vascular necrosis,or bone fracture, repairing the damage can involve surgical proceduresthat require operations such as precise drilling of holes in theglenoid, reaming a cavity in the humerus, and inserting an implant intothe cavity. Often, such procedures are done by surgeons using crudemethods that include eyeballing measurements and attempting to accountfor patient movement by hand. Especially with limited visibility and theintricate nature of the shoulder, techniques to provide a surgeon withgreater accuracy during shoulder repair or reconstruction would bebeneficial to patient outcomes.

Overview

Many examples exist of difficulties related to surgical procedures whereimprecision results in negative effects to the surgical result. In oneexample, during a shoulder procedure, when a guide pin is inserted intoa glenoid, difficulties arise when significant damage to the glenoid ispresented. Locating the precise location of the pin when significantdeformities in the joint exists is problematic. When the guide pin issecured to the glenoid, locating the guide pin at the incorrect locationand angle can have serious effects on the outcome of a surgery.Inserting the guide pin at the ideal location and orientation is furthercomplicated by the tight operating space, poor visibility, and complexnature of the shoulder joint. Accordingly, the present inventors havedetermined that use of an image guided robotic arm could be beneficialin ensuring proper placement and alignment of a guide pin for glenoidrepair.

As another example, when excavating bone through a burring process, thedepth, location and angle of the burring needs to be extremely preciseto ensure that excess bone is not removed. Removal of excess boneresults in weakening of the joint or bone and can be detrimental to thepatient. In shoulder reconstruction procedures, it is often necessary toreplace the head of the humerus, which requires reaming out a portion ofthe proximal humerus to receive a stem of a humeral implant(prosthesis).

As a solution to these types of surgical procedure difficulties, jigdevices are utilized. However, jig devices can be limited in theintraoperative adjustments to the surgical plan and can be prone tomanufacturing errors. These errors result in reverting to a conventionalshoulder procedure that requires cleaning off the labrum and other softtissues to achieve mating with the jig device.

Additionally, some current methods of shoulder fracture surgery andrepair are relatively primitive. As an example, with regard to fracturerepair, in an initial step, a canal needs to be reamed into the humerus.As a result of patient movement, and need to use landmarks to determineproper depth of the ream, over reaming is common. Cement then must beused to fill in and correct the over reaming, weakening the bone andcausing a potential loose fitting implant.

After the canal has been reamed as described above, a stem is placed inthe humeral canal. This is done by hand or with the assistance of manualsurgical instruments. Such manual surgical instruments can include afoam sleeve that can be placed around the stem in order to attempt tohold the stem in place. Still, significant give is provided in thesleeve causing movement in the stem. Alternatively, a nurse or assistantcan attempt to hold the stem to ensure proper placement, butimprecisions remain. Even when a limb positioner is employed to hold thehumeral bone in place, significant instability of the stem can occurduring the surgery.

Repairing a fractured shoulder joint can involve implanting a prosthesis(e.g., stem) and attaching bone fragments to the prosthesis and/orintact portion of the involved bones. In a fracture reconstructionsurgery, a surgeon often doesn't have enough hands to keep the stemstable and properly positioned while taking additional surgical stepssuch as adding the tuberosities (e.g., bone fragments) back to thehumerus. Consequently, this is a procedure that requires significantsurgeon skill to accurately perform. As the complexity of the fractureincreases, the degree of difficulty for the surgeon only rises. Thesetypes of imprecisions during surgery lead to problems for the patient,including but not limited to, improper tensioning in the shoulderreplacement assembly resulting in loss of movement, early failures inreplacement equipment, and additional surgeries.

In order to overcome these types of difficulties related to joint repairand replacement surgeries the inventors provide the current surgicalsystem. The surgical system can include a robotic system that receivesimages of a surgical area such as a joint or bone prior to surgery. Therobotic system can utilize an autonomously or semi-autonomouslycontrolled robotic arm and optionally one or more positionable surgicalsupport arms. A computing system associated with the robotic system cancreate a virtual model of the surgical area from medical images forplanning and execution of a surgical procedure. Based on the virtualmodel, one or more robotic arms of the robot can utilize surgicalinstruments to assist in performance of a surgical procedure. During theprocedure, a computer operated tracking system associated with therobotic system receives position data form tracking elements that havebeen placed on bones of the joint of the patient. Based on this positiondata, the robotic system makes real-time adjustments in the surgicalprocedure to account for movement. As a result of using the roboticsystem to generate the model and adjust a procedure using the positiondata, positioning of implants can be improved, and unnecessary reamingor burring of bones is minimized (if not eliminated).

The robotic surgical system discussed herein can be programmed tooperate autonomously, semi-autonomously, or through direct surgeoninput. In any of the three modes of operation, the robotic surgicalsystem can assist in precisely placing implants or performing operationsin reference to anatomical structures. The robotic system canpre-operatively create virtual models of the target bones and/or joint.The virtual models can be used for pre-operative planning, which canproduce instructions to direct operations of the robotic system during asurgical procedure. During the procedure, the robotic system can trackreference markers on the target anatomical elements (e.g., bones and/orjoints) to adjust planned implantations, resections, reaming, and otherrelated operations to be performed by the robotic system.

This Overview is intended to provide non-limiting examples of thepresent subject matter—it is not intended to provide an exclusive orexhaustive explanation. The Detailed Description below is included toprovide further information about the present apparatuses and methods.

BRIEF DESCRIPTION OF THE DRAWINGS

In the drawings, which are not necessarily drawn to scale, like numeralsmay describe similar components in different views. Like numerals havingdifferent letter suffixes may represent different instances of similarcomponents. The drawings illustrate generally, by way of example, butnot by way of limitation, various embodiments discussed in the presentdocument.

FIG. 1 illustrates a schematic diagram of a surgical system, inaccordance with at least one example of the disclosure.

FIG. 2 illustrates a perspective view of a glenoid receiving a guidepin, in accordance with at least one example of the disclosure.

FIG. 3 illustrates a flow chart for a method of inserting a guide pin ina glenoid, in accordance with at least one example of the disclosure.

FIG. 4 illustrates a manual technique for humeral head fracture repair.

FIGS. 5A-5B illustrate a perspective views of a humeral bone multi-partfracture, in accordance with at least one example of the disclosure.

FIG. 6 is a flowchart illustrating a technique for pre-operativeplanning for a robotically assisted fracture repair procedure, inaccordance with at least one example of the disclosure.

FIGS. 7A-7B are flowcharts illustrating robotically assisted fracturerepair techniques, in accordance with at least one example of thedisclosure.

FIG. 8A illustrates a perspective view of an implant and bone fragmentsof a humeral bone fracture, in accordance with at least one example ofthe disclosure.

FIG. 8B illustrates a perspective view of an implant and bone fragmentsof a humeral bone fracture, in accordance with at least one example ofthe disclosure.

FIG. 9 illustrates a flowchart for a method of repairing a humeral bonefracture, in accordance with at least one example of the disclosure.

FIG. 10 illustrates a flowchart for a method of testing the range ofmotion of a repaired shoulder, in accordance with at least one exampleof the disclosure.

FIG. 11 illustrates a flowchart for a method of burring a bone, inaccordance with at least one example of the disclosure.

FIG. 12 illustrates a schematic diagram of a system including amachine-readable medium, in accordance with at least one example of thedisclosure.

FIG. 13 illustrates a perspective view of a lockable surgical supportarm, in accordance with at least one example of the disclosure.

FIGS. 14A and 14B illustrate additional view of a lockable surgicalsupport arm, in accordance with at least one example of the disclosure.

FIGS. 15A and 15B are flowcharts illustrating surgical techniques usinga lockable surgical support arm, in accordance with at least one exampleof the disclosure.

FIG. 16 is a flowchart illustrating a surgical technique for conductingjoint analysis with assistance from a robotic arm, in accordance with atleast one example of the disclosure.

DETAILED DESCRIPTION

The present application relates to devices, systems and methods forperforming surgery on a surgical area such as a joint or individualbone. More specifically, the present application discusses a roboticsurgical system for assisting in joint repair and/or reconstructionprocedures. The Figures are all related to various examples of surgicalprocedures related to the shoulder joint, such as glenoid guide pinplacement, shoulder fracture repair, burring, reaming, and the like,relating to shoulder arthroplasty or repair surgeries. While not shown,other examples using similar systems, devices and methodologies arecontemplated. This includes, but is not limited to elbow replacement,thumb replacement, reverse shoulder replacement, rotator cuffarthroplasty, and the like.

FIG. 1 illustrates a surgical system 100 for operation on a surgicalarea 105 of a patient 110 in accordance with at least one example of thepresent disclosure. The surgical area 105 in one example can include ajoint and in another example, is a bone. The surgical area 105 caninclude any surgical area of the patient 110, including but not limitedto the shoulder, elbow, thumb, and the like. The surgical system 100also includes a robotic system 115 with one or more robotic arms, suchas robotic arm 120. As illustrated, the robotic system 115 will commonlyutilize only a single robotic arm. The robotic arm 120 can be a 6degree-of-freedom (DOF) robot arm, such as the ROSA robot from Medtech,a Zimmer Biomet Inc. company. In some examples, the robotic arm 120 iscooperatively controlled with surgeon input on the end effector orsurgical instrument, such as surgical instrument 125 (also referred toherein as end effector 125). In other examples, the robotic arm 120 canoperate autonomously. While not illustrated in FIG. 1, one or morepositionable surgical support arms can be incorporated into the surgicalsystem 100 to assist in positioning and stabilizing instruments oranatomy during a procedures. An example positionable surgical supportarm is illustrated in FIG. 13 and discussed in detail below in referenceto FIGS. 13-15B.

Each robotic arm 120 rotates axially and radially and receives asurgical instrument, or end effector, 125 at a distal end 130. Thesurgical instrument 125 can be any surgical instrument adapted for useby the robotic system 115, such as a gripping device such as a pincergrip, a burring device, a reaming device, an impactor device such as ahumeral head impactor, or the like. The surgical instrument 125 ispositionable by the robotic arm 120, which includes multiple roboticjoints, such as joint 135, that allows the surgical instrument 125 to bepositioned at any desired location adjacent or within a given surgicalarea 105.

The robotic system 115 also includes a computing system 140 thatoperates the robotic arms 120 and surgical instrument 125. The computingsystem 140 can include at least a memory, processing unit, and userinput devices, as will be described herein. The computing system 140also includes a human interface device 145 for providing images for asurgeon to be used during surgery. The computing system 140 isillustrated as a separate standalone system, but in some examples thecomputing system 140 can be integrated into the robotic system 115. Thehuman interface device 145 provides images, including but not limited tothree dimensional images of bones, glenoid, joints, and the like. Thehuman interface device 145 can include associated input mechanisms, suchas a touch screen, foot pedals, or other input devices compatible with asurgical environment.

The computing system 140 can receive pre-operative medial images. Theseimages are received in any manner and the images include, but are notlimited to computed tomography (CT) scans, magnetic resonance imaging(MRI), two dimensional x-rays, three dimensional x-rays, ultrasound, andthe like. These images in one example are sent via a server as filesattached to an email. In another example the images are stored on anexternal memory device such as a memory stick and coupled to a USB portof the robotic system to be uploaded into the processing unit. In yetother examples, the images are accessed over a network by the computingsystem 140 from a remote storage device or service.

After receiving one or more images, the computing system 140 cangenerate one or more virtual models related to surgical area 105.Specifically, a virtual model of the patient's anatomy can be created bydefining anatomical points within the image(s) and/or by fitting astatistical anatomical model to the image data. The virtual model, alongwith virtual representations of implants, can be used for calculationsrelated to the desired height, depth, inclination angle, or versionangle of an implant, stem, surgical instrument, or the like related tobe utilized in the surgical area 105. The virtual model can also be usedto determine bone dimensions, implant dimensions, bone fragmentdimensions, bone fragment arrangements, and the like. Any modelgenerated, including three dimensional models, can be displayed on thehuman interface for reference during a surgery or used by the roboticsystem 115 to determine motions, actions, and operations of a roboticarm 120 or surgical instrument 125. Known techniques for creatingvirtual bone models can be utilized, such as those discussed in U.S.Pat. No. 9,675,461, titled “Deformable articulating templates” or U.S.Pat. No. 8,884,618, titled “Method of generating a patient-specific boneshell” both by Mohamed Rashwan Mahfouz, as well as other techniquesknown in the art.

The computing system 140 also communicates with a tracking system 165that can be operated by the computing system 140 as a stand-alone unit.The surgical system 100 can utilize the Polaris optical tracking systemfrom Northern Digital, Inc. of Waterloo, Ontario, Canada. The trackingsystem 165 can monitor a plurality of tracking elements, such astracking elements 170, affixed to object of interest to track locationsof multiple objects within the surgical field. The tracking system 165functions to create a virtual three-dimensional coordinate system withinthe surgical field for tracking patient anatomy, surgical instruments,or portions of the robotic system 115. The tracking elements 170 can betracking frames including multiple IR reflective tracking spheres, orsimilar optically tracked marker devices. In one example, the trackingelements are placed on or adjacent one or more bones of the patient 110.In other examples, the tracking elements 170 can be placed on a robotrobotic arm 120, a surgical instrument 125, and/or an implant toaccurately track positions within a virtual coordinate system. In eachinstance the tracking elements provide position data, such as patientposition, bone position, joint position, robot robotic arm position,implant position, or the like.

The robotic system 115 can include various additional sensors and guidedevices. For example, the robotic system 115 can include one or moreforce sensors, such as force sensor 180. The force sensor can provideadditional force data or information to the computing system 140 of therobotic system 115. The force sensor 180 can be used to monitor impactor implantation forces during certain operations, such as insertion ofan implant stem into a humeral canal. Monitoring forces can assist inpreventing negative outcomes through force fitting components. In otherexamples, the force sensor 180 can provide information on soft-tissuetension in the tissues surrounding a target joint. In certain examples,the robotic system 115 can also include a laser pointer 185 thatgenerates a laser beam or array that is used for alignment of implantsduring surgical procedures.

As discussed above, shoulder joint reconstruction can involve placementof a guide pin. One known technique for implanting a guide pin is apatient-specific instrument (PSI) jig or guide. However, PSI jigs do noteasily allow for intraoperative adjustments to the surgical plan. PSIjigs can provide an opportunity for manufacturing errors in the PSI jigsto impact the surgical outcome, which may result in reverting to aconventional shoulder procedure. Additionally, PSI jigs can involveadditional surgical operations, such as cleaning off the labrum andother soft tissues to achieve a good mating surface on the bone.Utilizing the surgical system 100 can allow for intraoperativeadjustments to the surgical plan, as well as precise placement of theguide pin through use of the robotic arm.

FIG. 2 illustrates an example of a joint repair utilizing the surgicalsystem 100 of FIG. 1 to improve precision during a surgical procedure.In this example, the surgical procedure involves repair of a shoulderjoint 205 including securing a guide pin 210 to the glenoid 215. Asmentioned above, insertion of a glenoid guide pin, such as guide pin210, is potentially critical to a positive outcome in certain shoulderarthroplasty procedures. Inserting the guide pin at the proper locationand orientation (angle) can be challenging even when utilizing aninsertion guide instrumentation

FIG. 3 presents a flowchart outlining an example technique 300 to securethe guide pin 210 to the glenoid 215 using the example surgical system100 presented in FIG. 1. In this example, the technique 300 can includeoperations such as: receiving medical images of a glenoid at 305,generating a glenoid virtual model at 310, determining glenoiddimensions at 315, determining guide pin insertion plan at 320,initializing the surgical system at 325, and inserting the guide pin at330. The technique 300 can begin at 305 with images of the damagedglenoid being accessed by the computing system 140. At 310, thetechnique 300 continues with the computing system 140 of the surgicalsystem 100 generating a virtual model of the glenoid, based on the imagedata accessed by the computing system 140. At 315, the technique 300 cancontinue with the computing system 140 determining the dimensions of theglenoid based on measurements performed on the virtual model of theglenoid. In an example, edge detection and other similar imageprocessing techniques can be utilized to perform measurements on thevirtual model. In other examples, the computing system 140 can present auser interface to a medical professional to allow virtual measurementsto be made on the virtual model of the damaged glenoid. At 320,technique 300 can continue with the computing system 140 determining aninsertion plan including location, depth, and angle in the glenoid forplacement of the guide pin 210. In certain examples, the virtual modeland glenoid measurements can be utilized by the computing system 140 togenerate the insertion plan. In other examples, the computing system 140can generate a user interface that allows the medical professional toplan insertion of the guide pin in the virtual glenoid, with the userinterface providing visual and textual feedback regarding parametersrelevant to guide pin insertion.

Once the insertion plan has been generated and is available for repairof the damaged shoulder, the surgical system 100 can be initialized forthe procedure on the target patient. System initialization can includeloading the insertion plan into computing system 140 and registeringtracking markers affixed to necessary portions of the patient's anatomyand/or surgical instruments, among other things.

At 330, the technique 300 can proceed with the computing system 140instructing the robotic system 115 to insert the guide pin according tothe insertion plan. During operation 330, the computing system 140receiving tracking information from the tracking system 165 to instructthe robotic system 115 in real-time to adjust the insertion plan basedon tracked movements of the patient. Thus, the robotic system 115, basedtracking information providing the glenoid position, inserts the guidepin into the planned position within the glenoid. During the insertionprocess 330, the robotic system 115 can autonomously insert the guidepin. In other embodiments, the robotic system 115 can be guided by asurgeon and provide feedback in accordance with the insertion plan toensure the surgeon inserts the guide pin in the planned position andorientation. Guide pin insertion can include operations such as drillinga guide hole and then inserting the guide pin into the hole, or similaroperations.

By using the procedure discussed in reference to FIG. 3, the exactnessof the position of the guide pin is achieved without human error inplacement of the guide pin. In addition, because the computing system140 determines the exact location and angle of the guide pin (or allowsthe surgeon to pre-plan the location and angle), potential harm as aresult of a misplaced guide pin is minimized. Further, at least in theexamples where the robotic system 115 assists the surgeon, theexperience and expertise of the surgeon is leveraged to ensure theplanned insertion position and orientation are optimal. Therefore, theprocedure of FIG. 3 utilizing the surgical system of FIG. 1 can deliverimproved, consistent, and repeatable surgical results.

FIG. 4 illustrates a manual technique for humeral head fracture repairand FIGS. 5A-5B illustrate various humeral head fractures that can berepaired with assistance from the surgical system 100. As noted above,humeral head fractures can present numerous surgical challenges,including stabilizing a humeral implant while attending toreconstruction of the bone fragments (e.g., tuberosities). Repair of ahumeral head fracture can involve insertion of a humeral implant andreattachment of the fracture fragments, often referred to astuberosities. An example manual procedure is discussed in The AnatomicalShoulder™ Fracture System Surgical Technique from Zimmer Biomet, Inc. ofWarsaw, Ind. FIG. 4 includes a series of illustrations from the ZimmerBiomet surgical technique that highlight the complex nature of humeralhead fracture repair. As shown in FIG. 4, repairing the fractureinvolves inserting and stabilizing an implant and then reattaching thevarious tuberosities with various complex sutures (see sutures A, B, C₁,C₂, D and E).

In this example, the surgical system 100 of FIG. 1 can be used toimprove precision in surgery related to fracture repair surgery. FIGS.5A and 5B show examples of humeral fractures. FIG. 5A shows a four-partfracture where a humeral bone 400 is fractured into four separate bonefragments 405, 410, 415, 420. The fractured humeral bone 400 includes ahumeral shaft 405 with a fracture at a proximal end 425 where a greatertuberosity 410 and lesser tuberosity 415 fracture from the humeral shaft405 and humeral head 420. In FIG. 5B a three-part fracture is providedwhere the fracture results in three separate bone fragments 505, 510,515. In FIG. 5B the humeral bone 500 has a humeral shaft 505 with afracture at a proximal end 520 that includes a greater tuberosity 510and a lesser tuberosity 515. In this fracture a humeral head with alesser tuberosity 515 is provided as a single bone fragment. While FIGS.5A and 5B show three part and four part fractures, these are merelyexamples of fractures, the system is not necessarily limited to certainfracture types. The techniques and procedures discussed below involvingthe surgical system 100 in fracture repair are discussed, for purposedof example only, as operating on fractures with one greater tuberosityand one lesser tuberosity. However, the procedures can be adapted tofractures with more or fewer tuberosities involved in the fracture.

In a first example, the procedure for repairing a humeral head fractureutilizing the surgical system 100 involves using the robotic system 115to prepare the humerus, implant the stem of the humeral prosthesis, andstabilize the humeral prosthesis while the surgeon reconnects thetuberosities. In this example, the robotic system 115 can maintainprosthesis position and orientation, which can include depth ofinsertion into the humerus, inclination angle and version angle. Thisexample, leverages the skill and dexterity of the surgeon and variousstrengths of the robotic system 115, such as the ability to track andmaintain relative position between the humerus and the humeralprosthesis throughout the procedure. In this example, the robotic system115 can stabilize the prosthesis while bone cement is applied and/orafter application of bone cement to allow curing of the bone cement tocement the stem into the humerus.

In a second example, the procedure for repairing a humeral head fractureutilizing the surgical system 100 involves the robotic system 115performing or assisting in performance of all steps of the procedure. Inthis example, the procedure can be broken into various sub-procedures,including: pre-operative planning, humeral implant preparation andimplantation, and tuberosity reattachment of the tuberosities.Optionally, in this example, the surgeon may assist with reattachment ofthe tuberosities by performing the suturing or similar functions, whilethe tuberosity is held in position by the robotic system 115. In thisexample, image processing algorithms may be utilized to identify and mapthe tuberosities as well as suggest positions for reattachment of thetuberosities.

FIG. 6 is a flowchart illustrating a technique 600 for pre-operativeplanning for a robotically assisted fracture repair procedure, accordingto an example embodiment. The technique 600 can include operations suchas: accessing medical images of the fractured bone at 605, generating avirtual model of the fracture bone at 610, determining dimensions of thefractured bone at 615, determining implant parameters at 620, andgenerating a pre-operative plan at 625. Both of the example fracturerepair examples introduced above can utilize this pre-operative planningtechnique to prepare a fracture repair plan.

The technique 600 can begin at 605, with the computing system 140accessing medical images of fractured bone, such as fractured humerus400 or 500. The medical images can be MRI, CT, or x-rays image data. Theimage data accessed at 605 can include the fracture fragments. At 610,the computing system 140 of the robotic system 115 can create a virtualmodel of the fractured humeral shaft based on at least one receivedimage. In certain examples, the computing system 140 can also generatevirtual models for each of the fracture fragments. The virtual modelscan be created through computerized analysis of the medical images, suchas edge detection, blob analysis, surface fitting, and similar imageprocessing techniques to generate virtual approximations of thefragments. Planning for fracture repair can include utilizing image datafrom the patient's healthy shoulder to assist in generating a desiredoutcome model for the fracture repair. The healthy shoulder model can beutilized to assist the computing system 140 in determining how best toreassemble the tuberosities to best reform the humerus of the damagedshoulder. The computing system 140 can also analyze the various bonefragments to suggest a reassembly plan for the fragments.

At 615, the technique 600 can continue with the computing system 140determining dimensions of the fractured humeral shaft from the model. Incertain examples, operation 615 can include generating a user interfacefor presentation to the surgeon to confirm the determined dimensions. At620, the technique 600 can continue with the computing system 140determining implantation parameters for implanting the prosthesis. Inthe shoulder joint fracture repair examples, the parameters for thehumeral implant stem can include the location, angle (inclination andversion) and depth of a cavity to ream within the humeral shaft. Theimplant parameters can also include determination of insertion depth,inclination, and version of the actual humeral implant after the cavityis reamed in the humeral shaft. The parameters need to account for thefracture at the proximal end of the humeral shaft, which can bedetermined and accounted for based on the virtual model.

The technique 600 can conclude at 625 with the computing system 140generating a pre-operative plan. The pre-operative plan can includeinstructions to guide the robotic system 115 in performing or assistingwith the fracture repair.

FIG. 7A is a flowchart illustrating a robotically assisted fracturerepair technique 700A, according to an example embodiment. Technique700A illustrates a method utilizing the robotic system 115 to assist thesurgeon in performing fracture repair. In this example, the roboticsystem 115 facilitates inserting the prosthesis and maintaining positionof the prosthesis while the surgeon reattaches the fracture fragments(e.g., tuberosities). The technique 700A can include operations such as:accessing the pre-operative plan at 705, initializing the robotic systemat 710, reaming a cavity in the humeral shaft at 715, implanting theprosthesis at 720, and stabilizing the prosthesis at 725.

The technique 700A can begin at 705 with the computing system 140executing instructions to access a pre-operative plan, such as apre-operative plan generated with technique 600. At 710, the technique700A can continue with the computer system 140 operating to initializethe robotic system 115. Initializing the robotic system 115 can includecoordination with the optical tracking system 165, to general a virtualcoordinate system for the surgical field. Operation 710 can also includeoperations such as: registering the robotic arm 120 within a virtualcoordinate system; registering the virtual model from the pre-operativeplan to the physical anatomy including coordinating landmark locationson the physical anatomy to the virtual model; and displaying a userinterface to guide the surgeon through the planned operation, amongother things.

At 715, the technique 700A can continue with the robotic system 115performing a reaming operation to create a cavity in the humeral shaftto receive the planned prosthesis. The reaming operation can beperformed autonomously with the robotic system 115 and tracking system165 working in coordination to track the target bone and guide thereaming instrument to generate the planned cavity. In other examples,the surgeon can guide the robotic arm 120 through manipulation of areaming instrument attached to the end effector 125. In this example,the robotic system 115 can limit movements of the robotic arm 120 toprevent the surgeon from deviating from the planned resection.Throughout the cooperative control of the reaming instrument, therobotic system 115 can provide the surgeon opportunities to adjust theresection plan based on the surgeon's experience and ability to react toactual condition of the bone. The robotic system 115 can provide inputmechanisms, such as a touch screen, foot pedals or buttons on thereaming instrument that can allow the surgeon an opportunity tooverride, in a limited fashion, safety boundaries enforced by therobotic system 115 based on the pre-operative plan. As an additionalsafety measure, the override capabilities can be programmed to limitmovement or resection outside the plan to a pre-determined amount (anglevariation, distance variation, etc. . . . ).

Once the cavity is reamed, the technique 700A can continue at 720 withthe robotic system 115 performing prosthesis implantation into thereamed cavity. The pre-operative plan provides implant parameters, suchas depth into the cavity in the target bone, inclination, and version.Ideally, the cavity is reamed in such a manner through robotic controlthat depth, inclination, and version are largely dictated by the cavity.However, in some examples, the cavity will allow for some adjustment inthese parameters in implant insertion. Again, the prosthesis steminsertion can be performed autonomously by the robotic system 115 orcooperatively with the surgeon guiding movements of the robotic arm 120.In certain examples, securing the humeral stem in the reamed cavity mayrequire use of bone cement. In these examples, the robotic arm 120 canstabilize the humeral stem while the bone cement cures sufficiently tostabilize the implant.

At 725, the technique 700A continues with the robotic system 115 andtracking system 165 operating to stabilize the prosthesis and maintainthe planned position and orientation (e.g., depth, inclination, andversion) while the surgeon reattaches the tuberosities. As illustrated,operation 725 can include the tracking system 165 monitoring theprosthesis and target bone. Monitoring can be done, in an example, byaffixing tracking elements 170 to each of the prosthesis and the targetbone. In certain embodiments, a tracking element 170 will only beaffixed to the end effect 125 of the robotic arm 120 to closely monitorlocation of the prosthesis as it is held in place by an instrumentattached to the end effector 125. In yet another example, the roboticarm 120 can include sensors that allow for the robotic system 115 toknow the precise location of the robotic arm 120 and end effector 125,which can remove the need to a tracking element 170 to be affixed to therobotic arm 120 or the prosthesis during this operation. Operation 725can also include maintaining prosthesis stem orientation (e.g.,inclination and version) throughout this portion of the technique 700A.While the surgeon is working to reattach the tuberosities, slightmovement of the humerus may occur, and the robotic system 115 cancompensation for these movements through information provided by thetracking system 165. Finally, operation 725 can include maintainingprosthesis stem depth within the cavity in the target bone (e.g.,humerus). In some examples, the stem of the prosthesis can includemarkings that assist the surgeon in visually verifying that the roboticsystem 115 is maintaining proper depth and orientation. In otherexamples, the surgeon may utilize a marking instrument to mark the depthand/or orientation to allow for visual monitoring during the procedure.

FIG. 7B is a flowchart illustrating a robotically assisted fracturerepair technique 700B, according to an example embodiment. Technique700B illustrates a method where the robotic system 115 performs thefracture repair under supervision by the surgeon. In this example, therobotic system 115 is adapted to reassemble the tuberosities like ajigsaw puzzle. The initial operations of technique 700B are essentiallythe same as the operations discussed above in reference to technique700A. Operation 725 may deviate from the discussion above, as therobotic system 115 may optionally not continue to retain the prosthesisduring the reattachment process, but will at a minimum continue tomonitor the prosthesis location and orientation with reference to thetarget bone.

The unique aspects of technique 700B really being at operation 730,where the robotic system 115 operates to position bone fragments (e.g.,tuberosities) around the prosthesis to affect the repair. In thisexample, the pre-operative plan can include virtual models of the majortuberosities, those of sufficient size to allow for roboticreattachment. The virtual models of the tuberosities can be used by therobotic system 115 to identify, locate, and grasp the tuberosity duringoperation 730. In some examples, the robotic system 115 may includeadditional hardware devices to assist with this task, such as specialforceps or tweezers mounted on the end effector 125 that are speciallydesigned to enable the robotic arm 120 to grasp the tuberosities. Inanother example, the robotic system 115 may include a small suction-cuptype instrument mounted on the end effector 125 to grasp and positionthe tuberosities. Further, the robotic system 115 may include astereo-optic visual tracking device mounted near the end effect toprovide the robotic system 115 with the ability to identify and trackthe tuberosities within the surgical field. The robotic system 115 canutilize object recognition algorithms to identify the varioustuberosities, the prosthesis, and the fractured bone in order tocalculate the necessary trajectories to grasp and manipulate theindividual tuberosities into the planned position.

At 735, the technique 700B can continue with the robotic system 115reattaching the properly positioned tuberosities to the prosthesisand/or the fractured bone. The technique 700B may involve multipleiterations of operations 730 and 735 to address each of the tuberositiesto be reattached during the procedure. The reattachment process caninvolve suturing the tuberosity to the prosthesis and/or the fracturedbone. In an example, the robotic system 115 can be adapted toautonomously perform the suturing process. In other examples, therobotic system 115 can operation to hold the tuberosity in positionwhile the surgeon sutures it into place. Technique 700B can benefit froma robotic system with multiple robotic arms 120, which would allow forholding and suturing with separate robotic arms, for example,

At 740, the technique 700B can continue with the computing system 140accessing tracking data from the tracking system 165 and/or the roboticsystem 115 to verify that the prosthesis has been maintained in anoptimal position throughout the reattachment process. If the systemdetermines that the prosthesis has not maintained an optimal position,the technique 700B can continue at 745 with the computing system 140determining recommended prosthesis modifications to account for thesub-optimal positioning. For example, the prosthesis system may includevarious head and/or neck modules that can be substituted to account forthe actual position of the prosthetic stem.

FIG. 8A illustrates an example of an implant 800 that is inserted into acanal within a humeral shaft 805 that includes a central shaft axis 810during fracture repair surgery for humeral fractures including thoseshown in FIGS. 5A and 5B. The implant 800 can be implanted in accordancewith techniques 700A and 700B discussed above. The implant 800 includesa stem portion 815 at a distal end 820. While shown as having a uniformdiameter, the stem portion 815 in another example may taper. The stemportion 815 extends from the distal end 820 of the implant to adjacent ahumeral head 825 at a proximal end 830.

The humeral head 825 of the implant is generally rounded and has aproximal surface 832 and distal surface 835. The proximal surface 832 inone example is generally flat and in another example, is generallyspherical. The distal surface 835 in one example is generally flat andforms an angle α with a plane 845 defined by the engagement surface 850of the bone fragments 855 of the humeral head 860 of the patient.Rotation of the humeral head 825 of the implant 800 about the plane 845provides an inclination angle α of the implant.

The humeral head 825 of the implant 800 additionally has a central axis862 that aligns with the glenoid. The central axis 862 forms an angle θwith the central shaft axis 810 to define a version angle of the implant800.

Fin elements 865 extend from the stem portion 815 adjacent the humeralhead 825 of the implant for receiving the bone fragments 855 of thepatient's humeral head 860. In the example of FIG. 8a , where afour-part fracture is presented, the bone fragments 855 of the humeralhead 860 of the patient are a lesser tuberosity 870 and greatertuberosity 875 that engage the fin elements 865 as the lesser tuberosityand greater tuberosity 870, 875 are placed back together onto thehumeral shaft 805.

In the example of FIG. 8A a mark 880 is placed on the stem portion 815to provide a surgeon with reference regarding the height 885 of theimplant 800 compared to the humeral shaft 805. The height is thedistance between where the stem portion 815 is inserted into the humeralshaft 805 to the proximal end 830 of the implant 800. The mark 880 inone example is depth indicia placed on the stem portion 815. In anotherexample a laser of the surgical system produces a laser beam or arrayand tracks a specific point or location on the stem. The computer systemof the robotic system detects movement of the stem portion 815 and movesthe array accordingly to ensure the array is always at the same distancefrom an end of the stem portion 815.

FIG. 8B illustrates an example of the robotic system 115 of an examplesurgical system 100 holding the implant 800. In this example, thesurgical instrument 125 (end effector) of a robotic arm 120 is a pincergrip that grasps the humeral head 825 of the implant 800 at a desiredheight. Alternatively, the pincer grip or similar surgical instrumentaffixed to the end effector 125 can attach to an intermediate portion ofthe implant 800 that is designed to receive a humeral head. In thisexample, the end effector 125 can include an instrument adapted toattach to the implant in a manner similar to the humeral headattachment, but in a releasable manner. Upon obtaining the desiredplacement, including height, inclination and version angles, the pincergrip may take and place the lesser tuberosity and greater tuberosity870, 875 in place against the fin elements 865 and stem portion 815. Inone example, the pincer grip continues to hold the stem portion 815 inplace as a second robotic arm 120 of the robotic system 115 also has apincer grip that places the lesser tuberosity and greater tuberosity870, 875 in place about the fin elements 865 and stem portion 815.

FIG. 9 is a flow chart illustrating a methodology of repairing afracture 900 using an implant such as the one illustrated in the exampleof FIG. 8A. Technique 900 is an additional example of a roboticallyassisted fracture repair technique similar to techniques 700A and 700Bdiscussed above. The technique 900 can being at 905 with the computingsystem 1400 accessing images of fractured humeral bone obtained in anymanner as described above. At 910, the technique 900 can continue withthe computing system 140 of the robotic system 115 creating a model ofthe fractured humeral bone. At 912, the technique 900 continues with animplant model being obtained by the computing system 140 to be usedduring the repair. In one example, the implant model is obtained byreceiving the implant model from a remote source, such as on a memorydevice inserted into the computing device. In another example, theimplant model is generated by the computing system 140 based on imagesof an implant received by the computing system 140. In one example, theobtained implant model is a three-dimension model of the implant.

At 915, the technique 900 can continue with the computing systemdetermining the dimensions, including the size and shape of repairedhumeral bone using the implant. This includes a determination regardinghow bone fragments piece together about the implant and humeral shaft toreform the humeral bone with the implant. At 920, the technique 900 cancontinue with the computing system determining the required depth,inclination and version angles of the stem of the implant as it isinserted into a canal of the humeral shaft. In one example, the canal isreamed into the canal based on a pre-operative plan generated withrespect to the models of the fractured bone and implant. At 925, thetechnique 900 can optionally include placement of tracking elements onthe humeral shaft. Alternatively, operation 925 can involve thecomputing system 140 operating in cooperation with the tracking system165 to verify placement of the tracking elements on the fracturedhumerus and optionally on the implant.

At 930, the technique 900 can continue with the robotic system 115receiving the humeral shaft position from the tracking elements andoperating a gripping element such as a pincer grip at the distal end ofthe robotic arm of the robotic system to begin insertion of the stem ofthe implant into the canal of the humeral shaft. Alternatively, ahumeral head impactor is at the distal end of the robotic arm of therobotic system and engages the humeral head of the implant for insertioninto the canal. The robotic arm of the robotic system can detach fromthe head of the stem and the humeral head implant mates on the sameassembly that the robotic arm had been attached. At 935, the technique900 can continue with the tracking system monitoring the humeral shaftduring insertion of the stem for movement relative to the stem until thestem is at the desired depth, inclination and version angles.

Optionally, at 940, the technique 900 can continue with a depth linebeing marked on the stem. In an example, upon the stem of the implantreaching the desired depth, inclination and version angles, the roboticsystem marks with a depth line to indicate to a surgeon that the roboticarm is appropriately positioning the stem. The marking in one example isprovided by a laser pointer of the robotic system that focuses a laserbeam on the stem of the implant. At 945, the technique 900 can continuewith the robotic system 115 maintaining location and orientation of thestem. In an example, during fracture repair, the robotic arm of therobotic system maintains the stem at the depth, inclination and versionangles by physically retaining the stem. Upon detection of humeral bonemovement, the robotic arm of the robotic system adjusts the implant toensure the desired depth, inclination and version angles of the stem ofthe implant is provided.

At 950, the technique 900 can optionally continue with the trackingsystem 165 monitoring the depth, inclination and version angles of thestem of the implant. At 955, the technique 900 continues with thecomputer system 140 comparing the determined depth, inclination andversion angles of the stem of the implant, as determined by the trackingassembly of the robotic system, with the depth, inclination and versionangles of the stem of the implant determined prior to insertion todetermine if the depth, inclination and version angles of the stem ofthe implant match.

At decision 960, the technique 900 can continue with the computingsystem 140 of the robotic system 115 determining if the measured implantdata of 950 matches the pre-insertion determined implant data of 920. Ifthe desired depth, inclination and version angles of the stem of theimplant matches with the tracked depth, inclination and version anglesof the stem of the implant, then at 965 no additional action is taken bythe robotic system with regard to the depth, inclination and versionangles of the stem of the implant. If at decision 960 the desired depth,inclination and version angles of the stem of the implant does not matchwith the tracked depth, inclination and version angles of the stem ofthe implant, at operation 970, the computer system 140 can present amessage to the user interface device to use a different head or necksize of the implant to correct for the error.

At 975, the technique 900 can optionally continue with an auxiliary armof the robotic system having a gripping device autonomously places thebone fragments of the humeral bone in place based on the model of thehumeral bone. The bone fragments are thus matingly pieced together toreform the humerus. At 980, the bone fragments are attached to theimplant. As discussed above, reattachment can be performed by therobotic system 115 or the surgeon or a combination workingcooperatively. Additionally, operations 975 and 980 can be performediteratively on each fragment positioned for reattachment. At 975, thefirst bone fragment can be placed around the implant followed byattachment of the first fragment at 980. The technique 900 can return tooperation 975 to position the second bone fragment and continue tooperation 980 to attach the second bone fragment, with the techniqueiterating over operations 975 and 980 until all fragments to bereattached have been addressed.

By utilizing the methodology of FIG. 9, the robotic system maintains theexact depth, inclination and version angles of the stem of the implantduring repair so the surgeon can focus on other area of the repair.Additionally, the methodology allows for precise reconstruction of thebone fragments about the implant. In other methodologies, such as arevision fracture procedure when the humeral bone is desired to bereplaced all the way through the elbow, the laser pointer of the roboticsystem projects the desired alignment of the implant components down thelength of the arm of the patient.

FIG. 10 shows yet another flow chart of a methodology, this time amethodology for post-operative range of motion 1000 is provided. At 1005after surgery on a shoulder, a gripping device on the distal end of therobotic arm of a robotic system pulls the healthy arm of the patientthat was not operated upon. At 1010, a force sensor of the roboticsystem determines force data related to the range of motion of thehealthy arm. At 1015, the gripping device on the distal end of therobotic arm pulls the repaired arm of the patient that was operated uponwith the identical force and direction as related to the healthy arm. At1020, the force sensor of the robotic sensor determines force datarelated to the range of motion of the repaired arm. At 1025, the forcedata of the healthy arm and the force data of the repaired arm arecompared to determine the range of motion between the two arms.

Additional methodologies including using the surgical system 110 forburring processes 1100 is shown in FIG. 11. At 1105, images of thesurgical area are taken in any manner as described above. At 1110, thecomputing system of the robotic system creates a model of surgical areathat is to be burred. At 1115, the computing system determinesdimensions including the end dimensions of the bone to be burred. At1120, the computing system determines the location, angle and amount ofbone to be burred. At 1125, tracking elements are placed on the bonethat is to be burred.

At 1130, based on the bone position received by the robotic system fromthe tracking elements, burring of the bone occur. At 1135, duringburring of the bone the tracking system monitors the bone for movementrelative to the burr. At 1140, upon detection of movement of the bone,the robotic arm of the robotic system adjusts the burr position, angle,or depth based on the detected movement. Thus, as a result of themethod, burring is adjusted based on the movement to prevent overburring.

Method/technique examples described herein may be machine orcomputer-implemented at least in part. Some examples may include acomputer-readable medium or machine-readable medium encoded withinstructions operable to configure an electronic device to performmethods as described in the above examples. An implementation of suchmethods may include code, such as microcode, assembly language code, ahigher-level language code, or the like. Such code may include computerreadable instructions for performing various methods. The code may formportions of computer program products. Further, in an example, the codemay be tangibly stored on one or more volatile, non-transitory, ornon-volatile tangible computer-readable media, such as during executionor at other times. Examples of these tangible computer-readable mediamay include, but are not limited to, hard disks, removable magneticdisks, removable optical disks (e.g., compact disks and digital videodisks), memory cards or sticks, random access memories (RAMs), read onlymemories (ROMs), and the like.

FIG. 12 illustrates a schematic showing system 1200 that is an exampleof the computing system 140 of the surgical system 100. The system 1200can include local device 1201, user interface 1202, display 1204,interlink 1206, central device 1208, central device database 1210, andexpert device 1212. Local device 1201 can include processor 1214,volatile memory 1216, static memory 1218, and network device 1220.

Local device 1201 can be any computing device, such as a handheldcomputer, for example, a smart phone, a tablet, a laptop, a desktopcomputer, or any other computing device including information processingand storage capabilities and communication capabilities. Local device1201 can include processor 1214, volatile memory 1216, and staticmemory, which can be connected by wire or other electrical conduitwithin local device 1201 and can be configured to receive information,process information, output information, and store information. Theinformation can be temporarily stored on volatile memory 1216 and can berelatively permanently stored on static memory 1218. In some examples,configurations of these components within local device 1201 can beconsidered machine readable medium.

The terms “machine readable medium” may include any medium that iscapable of storing, encoding, or carrying instructions for execution bythe device and that cause the device to perform any one or more of thetechniques of the present disclosure, or that is capable of storing,encoding or carrying data structures used by or associated with suchinstructions. Non-limiting machine readable medium examples may includesolid-state memories, and optical and magnetic media. Specific examplesof machine readable media may include: non-volatile memory, such assemiconductor memory devices (e.g., Electrically Programmable Read-OnlyMemory (EPROM), Electrically Erasable Programmable Read-Only Memory(EEPROM)) and flash memory devices; magnetic disks, such as internalhard disks and removable disks; magneto-optical disks; and CD-ROM andDVD-ROM disks.

User interface 1202 can be any input and/or output device. For example,user interface can be a monitor, keyboard, and mouse in one example. Inother examples, user interface 1202 can be a touch screen display.Display 1204 can be a display for displaying output from local device1201 and in some examples, can receive input and transfer input to localdevice 1201 (for example a touch screen display).

Central device 1208 can be a remote device similar in configuration tolocal device 1201, but located remotely from local device 1201. Centraldevice 1208 can be configured to connect to multiple of local devices1201, in some examples, through interlink 1206. Similarly, expert device1212 can be a remote device similar in configuration to local device1201, but can be operated by a user considered to be an expert. Inoperation of some examples, the expert user can interface with theprocesses and decisions of the methods discussed herein.

In some examples, user interface and display 1204 can be connected tolocal device 1201 through wired connections, in some examples (such asUSB, for example), and through wireless connections (such as Bluetooth,for example) in other examples. In some other examples, interlink 1206can be a local area network (LAN), wide area network (WAN), and internetprotocol (TCP/IP) connections. Local device 1201 can be similarlyconnected to interlink 1206 (either through a wired or wirelessconnection). In some examples, network device 1220 can connect localdevice 1201 to interlink 1206. Central device 1208, central devicedatabase 1210, and expert device 1212 can be connected to interlink 1206in a similar manner.

In operation of some examples, system 1200 can be configured to performsteps of the methods discussed herein and in some examples, may performsteps based on a program stored in volatile memory 1216 or static memory1218, where results of the analysis are stored in either volatile memory1216 and/or static memory 1218 can be displayed on display 1204 and/ortransmitted to user interface 1202, central device 1208, central devicedatabase 1210, and/or expert device 1212. For example, system 1200 candevelop a model of a shoulder by receiving an image of a patientshoulder. One of local device 1201, central device 1208, and expertdevice 1212 can segment the image to develop a 3D shoulder model.

Similarly, system 1200 can be configured to perform steps of each methoddiscussed herein.

Thus, multiple methodologies for utilizing the surgical system 100 ofFIG. 1 are presented. In each, a robotic system is used to improveprecision and overall performance of a surgical procedure, includingpost procedure analysis. The improved performance is provided whilestill providing control to a surgeon to ensure the robotic system isperforming as desired.

In certain examples, a lockable surgical arm can be utilized instead ofor in addition to the robotic arm 120 to perform a segment of thefunctions discussed above, such as stabilizing the humerus or implantduring fracture repair. In some examples, the lockable surgical arm canbe used for fixed stabilization of the humerus under repair and/orstabilization of the implant in a desired location. While the lockablesurgical arm, discussed in greater detail below, stabilizes the humerusand/or implant, the robotic arm 120 can function to assist in reassemblyof fracture pieces. The lockable surgical discussed below provides aperfect mechanism to free up both the surgeon and the robotic arm 120 toperform more dynamic tasks. Further details on an examplerepositionable, lockable surgical arm system are provided in co-pendingapplications U.S. application Ser. No. 15/560,894, titled “RapidlyRepositionable Powered Support Arm,” filed Sep. 22, 2017; and U.S.application Ser. No. 15/918,531, titled “End Effector Coupler forSurgical Arm,” filed Mar. 12, 2018; both of which are herebyincorporated by reference in their entirety. The following introducesthe basic components of an example lockable surgical arm and details anexample surgical procedure utilizing the surgical arm in conjunctionwith the surgical system 100 discussed above.

FIG. 13 illustrates a perspective view of repositionable, lockablesurgical arm system 1300, in accordance with at least one example ofthis disclosure. The lockable surgical arm system 1300 can include table1302, arm 1304, tool (or instrument) 1305, and base unit 1306. Table1302 can include rail 1318. Base unit 1306 can include pole 1308 andmanual clamp 1310. Arm 1304 can include proximal joint 1311, actuatorunit 1312, distal joint 1313, proximal arm 1314, distal arm 1315, andinstrument holder 1318. Also shown in FIG. 13 are orientation indicatorsProximal and Distal (shown and discussed with respect to the adjustablearm).

Base unit 1306, which can be an electrically powered actuator, can besecured to railing 1316 of surgical table 1302 using, for example, aclamp. Manual clamp 1310 of base unit 1306 can be operated to tightenbase unit 1306 against railing 1316 and can also allow for adjustment ofpole 1308 to set a height of arm 1304 above surgical table 1302.

Electric actuator unit 1312 of arm 1304 can be located near a proximalend of arm 1304 and can be coupled to pole 1308 at proximal joint 1311.Electric actuator 1312 can also be coupled to a proximal portion ofproximal arm 1314. Proximal arm 1314 can be coupled to electric actuator1312 via a joint or as an actuatable part of actuator 1312 in otherexamples. Distal arm 1315 can be coupled to a distal portion of proximalarm 1314 via distal joint 1313. Instrument holder or end effectorcoupler 1318 can connect instrument 1305 to the distal end of arm 1304.In some examples, a lock/unlock button can be provided on or near endeffector coupler 1318.

The arms of lockable surgical arm system 1300 can comprise a seriallinkage of arm segments joined by spherical and rotational joints. Eachof joints 1311 and 1313 (and any other joints in other examples) can bepivotable and/or rotational joints allowing movement of connectedcomponents with one or more degrees of freedom. Joints 1311 and 1313(and joints within actuator 1312) can be locked and unlocked using baseunit 1306 and actuator 1312, which can be an electric bilateralactuator. In some examples, the joints of the arm are locked andunlocked with a fluid system.

While only proximal arm 1314 and distal arm 1315 are shown in FIG. 13,additional arm segments can be provided between actuator 1312 and endeffector coupler 1318. Each additional arm segment may require one ormore additional joint to form a repositionable, lockable support armstructure. Such additional arm segments can provide greater coverage andability for the arm be positioned with more degrees of freedom in thesurgical field.

In operation of some examples, the lock/unlock button can be operable bya user to initiate power locking and unlocking of arm 1304. When thelock/unlock button is not depressed arm 1304 can be in a locked statewhere joints 1311 and 1313 are locked such that proximal arm 1314 anddistal arm 1315 cannot move relative to each other or to table 1302.When the lock/unlock button is pressed, actuator 1312 can unlock joints1311 and 1313 such that end effector coupler 1318 can be positioned, asdesired, and as guided by joints 1311 and 1313 and proximal arm 1314 anddistal arm 1315. That is, end effector coupler 1318 can be moved to adesired position relative to body 50 through movement paths limited bythe freedom of arm 1304 to position instrument 1305 to a desiredposition relative to body 50.

FIG. 14A illustrates a perspective view of surgical arm system 1400, inaccordance with at least one example of this disclosure. FIG. 14Billustrates a perspective view of surgical arm 1400, in accordance withat least one example of this disclosure. FIGS. 14A and 14B are discussedbelow concurrently.

Surgical arm 1400 can include arm 1404, tool (or instrument) 1405, baseunit 1406 (only shown in FIG. 14B), control device 1407, pole 1408, andmanual clamp 1410. Arm 1404 can include proximal joint 1411, actuatorunit 1412, distal joint 1413, proximal arm 1414, distal arm 1415,coupler joint 1417, end effector coupler 1418, arm coupler 1419. Controldevice 1407 can include user interface 1420 and can be connected tocable 1422. Also shown in FIG. 14 are orientation indicators Proximaland Distal.

Surgical arm 1400 can be similar to system 1300 discussed above, exceptthat surgical arm 1400 can include different features. For example, baseunit 1406 can be a manually adjustable unit, where manual clamp 1410 canbe operable to adjust a position of base unit 1406 along a rail (e.g.,surgical table rail) and to adjust the height of pole 1408 (andtherefore arm 1404). In this example, control device 1407 can includeelectronic components configured to control arm 1404. For example,control device 1407 can house a controller (discussed further below) anduser interface 1420, which can include one or more control inputs (suchas buttons and switches) and can include audible or visual indicia.Cable 1422 can be coupleable to control device 1407 to connect alock/unlock button to control device 1407.

Surgical arm 1400 can also include arm coupler 1419 which can be adistal coupler of arm 1404 configured to releasably secure end effectorcoupler 1418 to coupler joint 1417 (and therefore to arm 1404). In otherexamples, discussed below, end effector coupler 1418 can be fixedlysecured to arm 1404.

Surgical arm 1404 can operate consistently with system 1300 describedabove, except that coupler joint 1417 can offer additional range ofmotion of the embodiment shown in FIG. 13. Further, end effector coupler1418 can be used to quickly and easily remove and secure tools andinstruments, such as tool 1405, to surgical arm 1404, as discussed infurther detail below.

FIGS. 15A and 15B are flowcharts illustrating surgical techniques usinga lockable surgical support arm, in accordance with at least one exampleof the disclosure. The techniques discussed in reference to thesefigures build on the techniques illustrated in FIGS. 7A and 7B,discussed above. In the example illustrated in FIG. 15A, the technique1500A can include operations such as accessing a pre-operative plan at1505; preparing a bone for an implant at 1510; implanting the prosthesis(implant) at 1515; attaching and positioning a surgical arm at 1520;stabilizing the bone and/or prosthesis during fragment reattachment at1525. Optionally, the operation for attaching and positioning thesurgical arm at 1520 can include attaching an end effector of thesurgical arm to a bone at 1521, attaching an end effector of thesurgical arm to a prosthesis at 1522, fixing the bone position at 1523and fixing the prosthesis position at 1524.

The technique 1500A can begin at 1505 with the computing system 140executing instructions to access a pre-operative plan, such as thepre-operative plan generated with technique 600 (discussed above). At1510, the technique 1500A can continue with operations necessary toprepare the bone for implantation of the prosthesis in accordance withthe pre-operative plan. The operation 1510 can include either manualpreparation of the bone by the surgeon in accordance with thepreoperative plan, or preparation of the bone using a robotic arm, suchas robotic arm 120. In an example utilizing the robotic arm 120, theoperation 1510 can include a number of operations discussed in referenceto FIG. 7A, including initializing the robotic system 115 at 710,reaming to create a cavity in the bone, such as the humeral shaft, usingthe robotic arm 120 at 715.

At 1515, the technique 1500A can continue with the robotic arm 120implanting the prosthesis in accordance with the pre-operative plan, asdiscussed in detail in reference to operation 720. In other examples,the surgeon can manually implant the prosthesis without assistance fromthe robotic arm 120. In yet other examples, the surgeon and robotic arm120 may operate cooperatively to perform the implantation, such as withthe surgeon guiding the robotic arm 120. Prosthesis implantation mayinclude the use of bone cement to hold the prosthesis in the bone. Inprocedures including the use of bone cement, securing the prosthesisrelative to the bone for a period of time can be important to allow thebone cement to cure.

Once the prosthesis is in place in the bone, such as within the reamedout cavity in the humerus, the technique 1500A can continue at 1520using one or more surgical support arms, such as surgical arm 1400, tomaintain position of the bone and/or prosthesis during subsequentoperations. In an example, a surgical arm 1400 can include an endeffector that couples to a portion of the bone, such as via a cuff orpadded clamping mechanism. At 1521, the technique 1500A can optionallycontinue with the surgical arm 1400 being attached to the bone. Onceattached to the bone, the technique 1500A can continue at 1523 with thesurgical arm 1400 being adjusted to position the bone as desired andthen locked into that position fixing the bone in the desiredorientation at 1523. In examples where a second surgical arm is used tocontrol the prosthesis, the technique 1500A can optionally continue withthe second surgical arm being attached to the prosthesis at 1522. Inthis example, the second surgical arm can include an end effectoradapted to easily couple to a portion of the prosthesis, such as thehumeral head or an upper segment of the humeral stem. Once the secondsurgical arm is coupled to the prosthesis, the technique 1500A canoptionally continue at 1524 with the second surgical arm being adjustedto position the prosthesis in the desired orientation, and then thesecond surgical arm can be locked to maintain the desired orientation ofthe prosthesis. The technique 1500A can complete at 1525 utilizing oneor more surgical support arms, such as surgical arm 1400, to stabilizethe bone and/or the prosthesis. In an example utilizing two surgicalsupport arms, the arms can maintain positioning of both the bone and theprosthesis, which can then allow a surgeon or a robotic arm performadditional tasks. In some examples, a single surgical support arm can beused with the robotic arm 120 operating to stabilize either the bone orthe prosthesis while the surgeon performs additional tasks, such asfracture repair or further securing the prosthesis with bone cement. Insome examples, one or more surgical support arms can be used to securethe prosthesis to allow bone cement time to cure, at least initially.

FIG. 15B illustrates a technique 1500B where one or more surgicalsupport arms are utilized to stabilize bone and/or prosthesis while asurgeon or robotic arm repairs a fracture. As illustrated in FIG. 4,fracture repair of a broken shoulder can be complicated and requirepositioning and reattachment of multiple bone fragments, whilemaintaining proper prosthesis positioning. As discussed in reference toFIG. 15A, one or more surgical support arms can be used to stabilizeboth the bone and the prosthesis, through operations 1505 through 1525.The technique 1500B can pick up at operation 1530 with the robotic armor the surgeon positioning bone fragments around the prosthesis, whilethe bone and prosthesis are stabilized. At 1535, the technique 1500B cancontinue with the surgeon (or in some cases the robotic arm) suturing orotherwise attaching the bone fragments to each other, the intact portionof the bone, and/or the prosthesis. In some examples, the robotic armcan be used to position the bone fragment, while the surgeon works tosecure it in place. Optionally, the technique 1500B can continue at 1540with the position of the prosthesis being verified after reattachment ofall bone fragments. Position verification can be done through landmarkson the prosthesis or through use of optical tracking markers on theprosthesis or the surgical support arm, among other methods. In certainexamples, the robotic arm 140 can be used to verify prosthesispositioning through contact with known positions on the prosthesis canbone landmarks. At 1545, the technique 1500B can optionally continuewith the computer system 140 calculating suggested modifications toprosthesis positioning after receiving input on the actual location ofthe prosthesis relative to the bone. The technique 1500B can iteratethrough operations 1540 and 1545 as necessary to achieve optimalprosthesis positioning.

Shoulder joint arthroplasty requires careful attention to preservationof soft tissue balance to maintain or regain proper range of motion inthe joint after implantation of a prosthesis. The shoulder is a complexjoint that requires ligaments and muscle to maintain proper stabilitythrough a wide range of motion desired from a healthy joint.Accordingly, during shoulder arthroplasty procedures it is beneficial toanalyze soft tissue conditions and select prosthetic implants that areproperly sized to obtain a desired amount of tension within the repairedjoint. If the soft tissues are loose the joint will have poor stability.If the tissues are too tight range of motion is be inhibited.

The robotic system 100 discussed above can be utilized to assist inassessing soft tissue conditions with the joint under repair and thecomputing system 140 can collect and analyze joint data to suggest anoptimal prosthesis for the observed conditions. In general, the roboticsystem 100 can be utilized to induce a known amount of tension into thejoint, and collect data regarding the reaction of the joint to theapplied tension. The collected data can include position and orientationof the bone associated with the joint, which can then be utilized toselect a proper prosthesis and guide additional surgical operations ifnecessary. Additional surgical operations can include soft tissuereleases or related repairs.

FIG. 16 is a flowchart illustrating a surgical technique for conductingjoint analysis with assistance from a robotic arm, in accordance with atleast one example of the disclosure. In this example, the technique 1600can include operations such as: coupling a robotic arm to a bone at1605; applying a force to the bone at 1610; collecting joint data at1615; optionally moving bone through a range of motion at 1620;optionally collecting additional joint data at 1625; analyzing jointbased on collected data at 1630; and selecting a prosthesis at 1635. Thetechnique 1600 can begin at 1605 with the robotic arm 120 being coupledto a patient's bone, such as a humerus. The robotic arm 120 can includean end effector that connects to an arm cuff or similar restrain toenable the robotic arm 120 to control the positioning of the humerus.The end effector can include a multiple degree of freedom coupling toenable the humerus to move in certain directions relatively freelyduring data collection, which enable collection of data related to howthe different soft tissues in the shoulder joint react to the forcesapplied by the robotic arm.

At 1610, the technique 1600 can continue with the robotic arm 120applying a force to the humerus, in this example. The force applied bythe robotic arm 120 can be applied along a vector calculated to separatethe humerus from the glenoid in a known manner that attempts to equallystress soft tissues within the shoulder joint. At 615, the technique1600 can continue with the computing system 140 collecting joint dataduring application of the force at 1610. The joint data can includeposition of the humerus relative to the glenoid, gap distances in theshoulder joint, and orientation of the humerus. The orientation of thehumerus can indicate relative tensions in the different soft tissues inthe shoulder joint.

At 1620, the technique 1600 can optionally continue with a range ofmotion test. In some examples, the robotic arm 120 can be programmed tomove the humerus through a range of motion. In other examples, thesurgeon can disconnect the robotic arm 120 and move the humerus throughthe range of motion manually. In either scenario, the technique 1600 canoptionally continue at 1625 with the computer system 140 collectingjoint data throughout the range of motion test. In an example, at leastsome of the joint data is collected through an optical tracking systemtracking optical tracking markers, such as optical tracking system 165tracking markers 170.

At 1630, the technique 1600 can continue with the computer system 140analyzing the joint data collected in operations 1615 and 1625. Theanalyzed data can then be used at 1635 by the computer system 140 toselect a prosthesis for use in repair of the shoulder based on the jointdata. For example, the gap size or average gap size over the range ofmotion may be used to assist in size selection of a prosthesis.

VARIOUS NOTES & EXAMPLES

Example 1 is a method of inserting a humeral implant into a humerus of apatient. The method includes receiving selection of a virtual humeralimplant including humeral implant dimensions; receiving a patientposition from one or more position sensors secured to the patient; andadjusting a position of the humeral implant relative to the humerusbased on at least one of the patient position, and the humeral implantdimensions.

In Example 2, the subject matter of Example 1 optionally includesdisplaying on a user interface device a graphic representation of thehumeral implant dimensions.

In Example 3, the subject matter of any one or more of Examples 1-2optionally include wherein the humeral implant dimensions includes oneor more of height, inclination, or version of the humeral implant.

In Example 4, the subject matter of any one or more of Examples 1-3optionally include reaming the humerus to create a humeral canal basedon at least one of the patient position, and the humeral implantdimensions.

In Example 5, the subject matter of Example 4 optionally includesinserting the implant into the humeral canal of the humerus with arobotic system based on at least one of the patient position and thehumeral implant dimensions.

In Example 6, the subject matter of Example 5 optionally includesreceiving an image of a patient shoulder comprising a humerus;developing a three-dimensional (3D) shoulder model.

In Example 7, the subject matter of Example 6 optionally includes Dshoulder model.

In Example 8, the subject matter of Example 7 optionally includesobtaining force data with a force sensor of the robotic system todetermine a post-surgery range of motion of the patient shoulder.

In Example 9, the subject matter of any one or more of Examples 1-8optionally include securing the humeral implant to the humerus whileimplant position is adjusted automatically based on at least one of thepatient position, the implant position, or the humeral implantdimensions.

In Example 10, the subject matter of Example 9 optionally includeswherein the implant position is adjusted by a robotic arm.

In Example 11, the subject matter of any one or more of Examples 9-10optionally include wherein the implant position is adjustedautomatically based on an image of a healthy shoulder of the patient.

In Example 12, the subject matter of any one or more of Examples 1-11optionally include receiving an image of a patient shoulder comprisingthe humerus, wherein the image of the patient shoulder is received fromat least one of computed tomography (CT) scan, magnetic resonanceimaging (MRI), ultrasound, two-dimensional x-ray, or three-dimensionalx-ray.

In Example 13, the subject matter of Example 12 optionally includescreating a three-dimensional model of a shoulder joint of a patient anda three-dimensional model of the implant.

In Example 14, the subject matter of Example 13 optionally includeswherein the image includes a plurality of bone fragments of the patient.

In Example 15, the subject matter of Example 14 optionally includesvirtually reassembling the plurality of bone fragments.

In Example 16, the subject matter of any one or more of Examples 1-15optionally include wherein the humeral implant is a humeral head implantthat includes an interface for an optical tracking assembly.

In Example 17, the subject matter of Example 16 optionally includesproviding an expected humeral head position; determining a humeral headposition with the optical tracking assembly; comparing the humeral headposition to the expected humeral head position to determine differencesin the expected humeral head position and humeral head position.

In Example 18, the subject matter of Example 17 optionally includeswherein the expected humeral head position is determined by opticalnavigation.

In Example 19, the subject matter of any one or more of Examples 17-18optionally include wherein the expected humeral head position andhumeral head position are the same.

In Example 20, the subject matter of any one or more of Examples 17-19optionally include wherein the expected humeral head position and thehumeral head position are different.

In Example 21, the subject matter of Example 20 optionally includesautomatically prompting a message on a user interface device to change ahead size or neck size of the humeral head implant.

In Example 22, the subject matter of any one or more of Examples 1-21optionally include the robotic system comprises a first robotic arm thatinserts the implant into the humeral canal of the humerus and a secondrobotic arm that holds the humerus during insertion of the implant intothe humeral canal.

In Example 23, the subject matter of any one or more of Examples 1-22optionally include aligning the humeral implant in the humerus with alaser pointer of a robotic system.

Example 24 is a method for guiding a surgical instrument, the methodcomprising: receiving an image of a glenoid in a three-dimensionalspace; tracking movement in glenoid position of a patient in thethree-dimensional space with a computer-operated tracking system;placing a guide pin within the glenoid with the surgical instrumentbased on the image of the glenoid and tracked movement in the glenoidposition.

In Example 25, the subject matter of Example 24 optionally includeswherein the image is at least one of computed tomography (CT) scan,magnetic resonance imaging (MRI), ultrasound, two-dimensional x-ray, orthree-dimensional x-ray.

In Example 26, the subject matter of any one or more of Examples 24-25optionally include tracking a humerus bone position within thethree-dimensional space using the computer-operated tracking system; andplacing the guide pin within the glenoid further based on the humerusbone position.

In Example 27, the subject matter of any one or more of Examples 24-26optionally include wherein a robotic system places the guide pin withinthe glenoid.

In Example 28, the subject matter of Example 27 optionally includeswherein the robotic system comprises the computer-operated trackingsystem and a robotic arm operated by the computer-operated trackingsystem.

In Example 29, the subject matter of Example 28 optionally includeswherein the robotic arm has a pincer grip to hold the guide pin.

In Example 30, the subject matter of any one or more of Examples 28-29optionally include wherein the computer-operated tracking systemactuates the robotic arm to position the guide pin.

In Example 31, the subject matter of any one or more of Examples 24-30optionally include wherein the computer-operated tracking systemcomprises an optical tracking assembly that receives input from at leastone tracking element secured to the glenoid.

Example 32 is a method for preparing a humeral bone for an implant, themethod comprising: tracking a humeral bone position within athree-dimensional space using a computer-operated tracking system of arobotic system; receiving an image of the humeral bone; reaming a canalwithin the humeral bone with a surgical instrument of a robotic system;during reaming, tracking movement in the humeral bone position; andadjusting position of the surgical instrument based on the movement inhumeral bone position.

In Example 33, the subject matter of Example 32 optionally includeswherein the surgical instrument is an effector of a robot arm of therobotic system.

In Example 34, the subject matter of Example 33 optionally includeswherein the effector is a reamer.

In Example 35, the subject matter of any one or more of Examples 32-34optionally include wherein the robotic system comprises a first roboticarm having a reamer for reaming the canal in the humeral bone and asecond arm having a gripping device to hold the humeral bone.

Example 36 is a surgical system comprising: a robotic system comprisinga computer-operated tracking system comprising at least one trackingelement that obtains position data related to a bone of a patient andsends the position data to the robotic system; and the robotic systemcomprising a robotic arm that moves in relation to the bone based on theposition data related to the bone obtained by the at least one trackingelement.

In Example 37, the subject matter of Example 36 optionally includeswherein the robotic arm includes a surgical instrument that comprises aburring device for removing bone.

In Example 38, the subject matter of any one or more of Examples 36-37optionally include wherein the computer-operated tracking system has anoptical navigation assembly.

In Example 39, the subject matter of any one or more of Examples 36-38optionally include wherein the robotic system further comprises a userinterface device to present a graphic representation of an implant beinginserted into the bone.

In Example 40, the subject matter of any one or more of Examples 36-39optionally include wherein the robotic system receives an image of apatient shoulder and forms a model of the patient shoulder.

In Example 41, the subject matter of Example 40 optionally includeswherein the image of the patient shoulder is received from at least oneof computed tomography (CT) scan, magnetic resonance imaging (MRI),ultrasound, two-dimensional x-ray, or three-dimensional x-ray.

In Example 42, the subject matter of any one or more of Examples 36-41optionally include wherein the robotic system further comprises a forcesensor for receiving force data related to the bone.

In Example 43, the subject matter of any one or more of Examples 36-42optionally include an implant releasably secured by an arm of therobotic system for placement in the bone.

In Example 44, the subject matter of Example 43 optionally includeswherein the implant is a humeral head implant that includes an interfacefor the computer-operated tracking system.

In Example 45, the subject matter of Example 44 optionally includeswherein the computer-operated tracking system has an optical trackingassembly.

In Example 46, the subject matter of any one or more of Examples 36-45optionally include wherein the robotic system further comprises a firstrobotic arm that inserts an implant into the bone and a second roboticarm that holds the bone during insertion of the implant.

In Example 47, the subject matter of any one or more of Examples 36-46optionally include wherein the robotic system further comprises a laserpointer for aligning an implant in the bone.

Each of these non-limiting examples can stand on its own, or can becombined in various permutations or combinations with one or more of theother examples.

The above detailed description includes references to the accompanyingdrawings, which form a part of the detailed description. The drawingsshow, by way of illustration, specific embodiments in which theinvention can be practiced. These embodiments are also referred toherein as “examples.” Such examples can include elements in addition tothose shown or described. However, the present inventors alsocontemplate examples in which only those elements shown or described areprovided. Moreover, the present inventors also contemplate examplesusing any combination or permutation of those elements shown ordescribed (or one or more aspects thereof), either with respect to aparticular example (or one or more aspects thereof), or with respect toother examples (or one or more aspects thereof) shown or describedherein.

In the event of inconsistent usages between this document and anydocuments so incorporated by reference, the usage in this documentcontrols.

In this document, the terms “a” or “an” are used, as is common in patentdocuments, to include one or more than one, independent of any otherinstances or usages of “at least one” or “one or more.” In thisdocument, the term “or” is used to refer to a nonexclusive or, such that“A or B” includes “A but not B,” “B but not A,” and “A and B,” unlessotherwise indicated. In this document, the terms “including” and “inwhich” are used as the plain-English equivalents of the respective terms“comprising” and “wherein.” Also, in the following claims, the terms“including” and “comprising” are open-ended, that is, a system, device,article, composition, formulation, or process that includes elements inaddition to those listed after such a term in a claim are still deemedto fall within the scope of that claim. Moreover, in the followingclaims, the terms “first,” “second,” and “third,” etc. are used merelyas labels, and are not intended to impose numerical requirements ontheir objects.

Method examples described herein can be machine or computer-implementedat least in part. Some examples can include a computer-readable mediumor machine-readable medium encoded with instructions operable toconfigure an electronic device to perform methods as described in theabove examples. An implementation of such methods can include code, suchas microcode, assembly language code, a higher-level language code, orthe like. Such code can include computer readable instructions forperforming various methods. The code may form portions of computerprogram products. Further, in an example, the code can be tangiblystored on one or more volatile, non-transitory, or non-volatile tangiblecomputer-readable media, such as during execution or at other times.Examples of these tangible computer-readable media can include, but arenot limited to, hard disks, removable magnetic disks, removable opticaldisks (e.g., compact disks and digital video disks), magnetic cassettes,memory cards or sticks, random access memories (RAMs), read onlymemories (ROMs), and the like.

The above description is intended to be illustrative, and notrestrictive. For example, the above-described examples (or one or moreaspects thereof) may be used in combination with each other. Otherembodiments can be used, such as by one of ordinary skill in the artupon reviewing the above description. The Abstract is provided to complywith 37 C.F.R. § 1.72(b), to allow the reader to quickly ascertain thenature of the technical disclosure. It is submitted with theunderstanding that it will not be used to interpret or limit the scopeor meaning of the claims. Also, in the above Detailed Description,various features may be grouped together to streamline the disclosure.This should not be interpreted as intending that an unclaimed disclosedfeature is essential to any claim. Rather, inventive subject matter maylie in less than all features of a particular disclosed embodiment.Thus, the following claims are hereby incorporated into the DetailedDescription as examples or embodiments, with each claim standing on itsown as a separate embodiment, and it is contemplated that suchembodiments can be combined with each other in various combinations orpermutations. The scope of the invention should be determined withreference to the appended claims, along with the full scope ofequivalents to which such claims are entitled.

The claimed invention includes:
 1. A method of inserting a humeralimplant into a humerus of a patient, the method comprising: receivingselection of a virtual humeral implant including humeral implantdimensions; creating a three-dimensional (3D) model of a shoulder jointof a patient based on an image of the shoulder joint and athree-dimensional model of the virtual humeral implant, wherein theimage includes a plurality of bone fragments of the patient; receiving apatient position from one or more position sensors secured to thepatient; and adjusting, using a robotic manipulator, a position of thehumeral implant relative to the humerus based on at least one of thepatient position, the humeral implant dimensions, and the 3D model. 2.The method of claim 1, further comprising: displaying on a userinterface device a graphic representation of the humeral implantdimensions.
 3. The method of claim 1, further comprising: wherein thehumeral implant dimensions include one or more of height, inclination,and version of the humeral implant.
 4. The method of claim 1, furthercomprising: reaming the humerus to create a humeral canal based on atleast one of the patient position and the humeral implant dimensions. 5.The method of claim 4, further comprising: inserting the implant intothe humeral canal of the humerus with the robotic manipulator based onat least one of the patient position and the humeral implant dimensions.6. The method of claim 5, wherein the robotic manipulator comprises afirst robotic arm that inserts the implant into the humeral canal of thehumerus and a second robotic arm that holds the humerus during insertionof the implant into the humeral canal.
 7. The method of claim 1, furthercomprising: placing, matingly, at least a portion of the plurality ofbone fragments together with the robotic manipulator based on the 3Dshoulder model.
 8. The method of claim 7, further comprising: obtainingforce data with a force sensor disposed on the robotic manipulator todetermine a post-surgery range of motion of the patient shoulder.
 9. Themethod of claim 1, further comprising: securing the humeral implant tothe humerus while implant position is adjusted automatically based on atleast one of the patient position, the implant position, or the humeralimplant dimensions.
 10. The method of claim 9, wherein the implantposition is adjusted by a robotic arm.
 11. The method of claim 9,wherein the implant position is adjusted automatically based on an imageof a healthy shoulder of the patient.
 12. The method of claim 1, furthercomprising: virtually reassembling the plurality of bone fragments. 13.The method of claim 1, wherein the humeral implant is a humeral headimplant that includes an interface for an optical tracking assembly; andwherein the method further comprises: providing an expected humeral headposition; determining a humeral head position with the optical trackingassembly; and comparing the humeral head position to the expectedhumeral head position to determine differences in the expected humeralhead position and humeral head position.
 14. The method of claim 13,wherein the expected humeral head position is determined by opticalnavigation.
 15. The method of claim 13, further comprising:automatically prompting a message on a user interface device to change ahead size or neck size of the humeral head implant.
 16. A method ofinserting a humeral implant into a humerus of a patient, the methodcomprising: receiving selection of a virtual humeral implant includinghumeral implant dimensions; receiving an image of a patient shouldercomprising a humerus; developing a three-dimensional (3D) shouldermodel; receiving a patient position from one or more position sensorssecured to the patient; and adjusting, using a robotic manipulator, aposition of the humeral implant relative to the humerus based on atleast one of the patient position, the humeral implant dimensions, andthe 3D shoulder model; and placing, matingly, bone fragments togetherwith the robotic manipulator based on the 3D shoulder model.
 17. Themethod of claim 16, further comprising: reaming the humerus to create ahumeral canal based on at least one of the patient position and thehumeral implant dimensions.
 18. The method of claim 17, furthercomprising: inserting the implant into the humeral canal of the humeruswith the robotic manipulator based on at least one of the patientposition and the humeral implant dimensions.